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Clinical neuro-otology of spatial orientation

      Difficulties in understanding symptoms in patients with chronic dizziness have turned our attention to perceptual and cortical aspects of vestibular processing. Early indication that these processes were important in recovery from peripheral vestibular disorders came from findings in a non-selected group of such patients where we found that abnormalities in vestibularly-mediated spatial orientation correlated well with symptoms of depersonalization and derealisation (Jauregui-Renaud et al; J Neurol Neurosurg Psychiatry. 2008;79:276-83). Further indication that cortical mechanisms are involved in clinical recovery came from cross sectional (Cousins et al; PLoS One. 2014;9:e105426; Patel et al; Otol Neurotol. 2016;37:179-84) and longitudinal studies in patients with vestibular neuritis (Cousins et al; Ann Clin Transl Neurol. 2017;Mar 22;4:340-346). These studies show that good clinical outcome depends on perceptual visuo-vestibular reweighting processes (visual dependence) and psychological variables but not on peripheral vestibular recovery (caloric or head-impulse tests). As to what cortical areas participate in the control of vestibularly-based spatial orientation we will review our work with transcranial magnetic stimulation (Seemungal et al; Neurosci Lett. 2008;437:88-92), functional imaging (Roberts et al; Brain Struct Funct. 2016.[Epub ahead of print]PMID: 27942855), and stroke patients (Pérennou et al; Brain. 2008;131:2401-13); (Kaski et al; Brain. 2016;139:392-403) showing that the parietal cortex, temporo-parieto-occipital junction and the posterior insula are critically involved in these processes. Of practical relevance to researchers are the emerging concepts of inter-hemispheric lateralization and interaction in vestibular control, with right-sided hemispheric dominance in right-handers for vestibular cortical processing (Nigmatullina et al; Brain Stimul. 2016;9:942-944) (Arshad et al; J Neurosci. 2013;33:3221-7).
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